A pregnant client with a history of heroin use is admitted to the birthing unit. The client is currently in a treatment program and has been on stable doses of methadone during her pregnancy. She tells the nurse, “I know my baby may go through withdrawal after delivery. What will happen?” The nurse correctly tells her that her baby may: (Select all that apply)
Sleep deeply.
Have a high-pitched cry.
Not feed well.
Have some shaking.
Sweat a lot.
Correct Answer : B,C,D,E
Choice A rationale
Deep sleep is not a characteristic of neonatal abstinence syndrome; rather, infants tend to exhibit irritability and disturbed sleep patterns due to central nervous system hyperirritability caused by opioid withdrawal.
Choice B rationale
A high-pitched cry occurs due to central nervous system overstimulation and hyperirritability, which are hallmark features of neonatal abstinence syndrome and a direct result of opioid withdrawal in neonates.
Choice C rationale
Poor feeding is common in neonatal abstinence syndrome due to uncoordinated suck reflexes and gastrointestinal disturbances, leading to difficulty maintaining adequate nutrition and hydration in affected neonates.
Choice D rationale
Neonates with neonatal abstinence syndrome often exhibit tremors or shaking as a result of central nervous system hyperirritability, which is a hallmark symptom of opioid withdrawal in newborns.
Choice E rationale
Excessive sweating is a manifestation of autonomic nervous system dysregulation caused by opioid withdrawal in neonates, commonly observed in infants with neonatal abstinence syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
Correct Answer is A
Explanation
Choice A rationale
Chlorhexidine is a broad-spectrum antiseptic effective against gram-positive and gram-negative bacteria. It is safe for patients allergic to betadine and reduces infection risks during catheter insertion.
Choice B rationale
Betadine, containing povidone-iodine, is contraindicated in patients with allergies to iodine. Using it could trigger allergic reactions, including anaphylaxis, compromising patient safety.
Choice C rationale
Sterile water lacks antiseptic properties and does not provide necessary antimicrobial activity to minimize infection risks, making it unsuitable for catheter insertion.
Choice D rationale
Alcohol wipes can cause tissue irritation and discomfort during catheter insertion. They are less effective against bacterial spores, reducing their efficacy for preventing infections in this context.
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